FIRST SET OF QUESTIONAIRE

I. Multiple Choice. Write your answers beside the number 5. In the emergency room department, a child was rushed
ONLY. due to difficulty of breathing due to asthma attack. What is
the least nursing action?

A. Provide health teaching to the family

1. In the pediatric surgical ward, you have been assigned to
one-month-old child with cleft lip and palate. You have to B. Check for airway patency
teach the mother with proper way of providing nutrition to the
child. The following are correct steps except: C. Request for Chest X-ray STAT

A. Use rubber nipples with small opening in order to prevent D. Give hydrocortisone STAT
aspiration

B. Place the child in a semi-upright position when feeding.

6. One night, a child was rushed in an emergency room with
C. Feeding session should be done slowly the following symptoms: fear of physical contact,
apprehensive, bruises all over the body. These are possible
D. Teach the mother to stimulate the sucking reflex by signs of:
rubbing the nipple against the lower lip of the baby.
A. Physical abuse

B. Fall
2. You were then asked by the mother when is the best time
for surgical intervention for a cleft palate? C. Vehicular accident

A. One to three months old D. Victim of Neglect

B. Four to seven months old only

C. Eight to eleven months old 7. A nurse is describing the process of fetal circulation to a
client during a prenatal visit. The nurse accurately tells the
D. Six months to eighteen months old client that fetal circulation consists of:

A. Two umbilical veins and one umbilical artery

3. A child has been recovering from an operation of the cleft B. Two umbilical arteries and one umbilical vein
lip. What is your priority nursing care?
C. Arteries carrying oxygenated blood to the fetus
A. Bleeding tendency
D. Veins carrying deoxygenated blood to the fetus
B. Wound care

C. Airway patency
8. A nursing instructor asks a nursing student who is
D. Risk for infection preparing to assist with the assessment of a pregnant client
to describe the process of quickening. Which of the following
statements if made by the student indicates an
understanding of this term?
4. A mother would like to know the reason why there is
asthma in her child. How would you explain it? A. “It is the irregular, painless contractions that occur
throughout pregnancy.”
A. An asthma attack is a response to release of inflammatory
mediators to epithelial cells. The autonomic neural control to B. “It is the soft blowing sound that can be heard when the
airway is affected. uterus is auscultated.”

B. An asthma attack can happen when the child is exposed C. “It is the fetal movement that is felt by the mother.”
to certain allergens that would trigger an allergic reaction to
the bronchioles causing constriction of the bronchial tree. D. “It is the thinning of the lower uterine segment.”
This is either acquired or being hereditary.

C. An asthma attack is an inborn problem of a child that

involves abnormal growth of the bronchial tree causing 9. A nurse is providing instructions to a client in the first
restriction. trimester of pregnancy regarding measures to assist in
reducing breast tenderness. The nurse tells the client to:
D. All of these
A. Avoid wearing a bra
B. Wash the nipples and areola area daily with soap, and C. Do not give snacks to the child before meals
massage the breasts with lotion.
D. Provide quiet environment for the child before meals
C. Wear tight-fitting blouses or dresses to provide support

D. Wash the breasts with warm water and keep them dry
14. The nurse is drawing blood from the diabetic patient for a
glycosolated hemoglobin test. She explains to the woman
that the test is used to determine:
10. A client in the first trimester of pregnancy arrives at a
A. Her usual fasting glucose level.
health care clinic and reports that she has been experiencing
vaginal bleeding. A threatened abortion is suspected, and B. Glucose levels over the past several months.
the nurse instructs the client regarding management of care.
Which statement, if made by the client, indicates a need for C. The highest glucose level in the past week.
further education?
D. Her insulin level.
A. “I will maintain strict bedrest throughout the remainder of
pregnancy.”

B. “I will avoid sexual intercourse until the bleeding has 15. How does the nurse appropriately administer mycostatin
stopped, and for 2 weeks following the last suspension in an infant?

evidence of bleeding.” A. Mix mycostatin with formula

C. “I will count the number of perineal pads used on a daily B. Have the infant drink water, and then administer
basis and note the amount and color of blood on the pad.” mycostatin in a syringe

D. “I will watch for the evidence of the passage of tissue.” C. Place mycostatin on the nipple of the feeding bottle and
have the infant suck it

D. Swab mycostatin on the affected areas.

11. The nurse is assessing a newborn who had undergone
vaginal delivery. Which of the following findings is least likely
to be observed in a normal newborn?
16. The nurse answers a call bell and finds a frightened
A. (+) moro reflex mother whose child, the patient, is having a seizure. Which
of these actions should the nurse take?
B. Respirations are irregular, abdominal, 30-60 bpm
A. The nurse should help the mother restrain the child to
C. Uneven head shape prevent him from injuring himself.

D. Heart rate is 80 bpm B. The nurse should clear the area and position the client
safely.

C. The nurse should insert a padded tongue blade in the

12. Which of the following would be inappropriate when patient’s mouth to prevent the child from swallowing or
administering chemotherapy to a child? choking on his tongue.
A. Administering medication through a free-flowing D. The nurse should call the operator to page for seizure
intravenous line assistance.
B. Observing the child for 10 minutes to note for signs of
anaphylaxis
17. Which of the following blood study results would the
C. Assessing for signs of infusion infiltration and irritation nurse expect as most likely when caring for the child with
iron deficiency anemia?
D. Monitoring the child for both general and specific adverse
effects A. Decreased mean corpuscular volume (MCV)

B. Normal total iron-binding capacity (TIBC)

13. A mother tells the nurse that she is very worried because C. Increased hemoglobin
her 2-year old child does not finish his meals. What should
the nurse advise the mother? D. Normal hematocrit

A. Make the child seat with the family in the dining room until
he finishes his meal

B. Put the child on a chair and feed him

18. You are assigned in a Reproductive Clinic, as a nurse it B. Female fetus
is your task to give counsel to young couples. These are the
natural methods except: C. Preeclampsia

A. Abstinence D. Oligohydramnios

B. Coitus Interruptus

C. Calendar Guided -Pills 24. All of these factors can lead to a nonreactive NST
except:
D. Calendar Method
A. Fetal hypoxia and asphyxia

B. Smoking
19. A pregnant mother complained of excessive vaginal
discharge. Which of the following assessment would signal a C. Stimulants
referral to the doctor?
D. Gestational age
A. Excess discharge
E. Behavioral states
B. Itching sensation

C. Discomfort
25. A 28-year-old patient, who is 28 weeks’ pregnant,
D. Wet feeling presents with increasing pruritis for 3 days. She has mild
nausea but no other symptoms. She received amoxicillin 5
days ago for urinary tract infection (UTI), and is still taking
the medication. On examination, she has some excoriations
20. As a nurse, when a patient has Diabetes on pregnancy, on the arms and legs, normal vital signs, and no icterus. Her
these are complications that must be prevented except: CBC was normal; TBR 0.9, AST 150, ALT 70, ALP 120,
GGT 70, INR 1.1. Abdominal ultrasound showed normal
A. Polyhydramios liver, distended gallbladder with some sludge, and common
bile duct (CBD) 8 mm in diameter with no obvious stones.
B. Stillbirth
The most likely diagnosis is:
C. Low birth weight
A. Biliary obstruction due to a small stone in CBD
D. Pregnancy Induced Hypertension
B. Allergic reaction to amoxicillin
21. What is the major risk factor for ectopic pregnancy?
C. Intrahepatic cholestasis of pregnancy
A. The use of an intrauterine contraceptive device
D. Normal expectation in a pregnant woman
B. Previous pelvic inflammatory disease

C. Cigarette smoking
26. One of your young patients, who is 24 years old, has
D. Medical abortion been diagnosed recently with autoimmune hepatitis, and
started on treatment with steroids and azathioprine. Her
E. Salpingitis isthmica nodosa steroids are being tapered. She desperately wants to have a
child. You can advise the following:

A. Autoimmune hepatitis and other chronic liver diseases

22. What is the first stage in the laboratory evaluation of decrease fertility, and she is not likely to be able to get
women with a suspected ectopic pregnancy? pregnant. She should think about adoption

A. Abdominal ultrasound B. After successful treatment of autoimmune hepatitis,

fertility is likely to return, and she can get pregnant. She will
B. Vaginal ultrasound have to continue azathioprine and, at low doses, the
teratogenic risk of this drug is low
C. Pregnancy test (β-hCG enzyme immunoassay)
C. Her fertility is not affected at all by chronic liver disease,
D. Serum progesterone measurements
and she has a normal chance of getting pregnant and having
E. Dilation and curettage a baby

D. She has a chance of getting pregnant even when the

disease is active, but you will advise her against it because
23. Which of the following is a risk factor for macrosomia? of the teratogenic side-effects of azathioprine

A. Diabetes mellitus
27. An immediate Cesarean section is the unequivocal neonatal behavioral states B. The fetus spends its time
management option for which clinical scenario? predominantly in either a quiet or an active awake state

A. Active genital HSV in a patient with premature rupture of C. Quiet sleep is characterized by reduced fetal heart rate
the membranes at 28 weeks (FHR) variability and no accelerations

B. Active labor at term in a patient with acute primary HSV D. Active sleep is characterized by infrequent gross body
movements, but rapid eye movements and breathing
C.Active labor at term in a patient with recurrent HSV in the
buttocks D. Active labor at term in a patient with shingles E. Both B and D

28. Which clinical scenario is most likely to result in fetal 33. The nurse understands that the fetal head is in which of
infection? A.A mother who develops chickenpox on the first the following positions with a face presentation?
postpartum day following vaginal delivery
A. Completely extended
B. A mother with active shingles who undergoes an
emergency Cesarean delivery for a bleeding placenta previa B. Partially flexed

C. A pregnant woman with varicella pneumonia at 20 weeks, C. Partially extended

who undergoes a Cesarean delivery at term because of a
breech presentation D. Completely flexed

D. A mother who develops chickenpox 2 weeks after delivery

34. Which of the following refers to the single cell that

reproduces itself after conception?
29. How many g/day will the fetus gain at 32–34 weeks of
gestation? A. Trophoblast

A. 10–15 g B. Chromosome

B. 20–25 g C. Blastocyst

C. 30–35 g D. Zygote

D. 40–45 g

35. A client has a midpelvic contracture from a previous

pelvic injury due to a motor vehicle accident as a teenager.
30. Which of the following conditions is not associated with The nurse is aware that this could prevent a fetus from
fetal growth restriction? passing through or around which structure during childbirth?
A. Abnormal fetal heart rate pattern during labor A. Pubic Arch
B. Oligohydramnios B. Ischial Spine
C. Post date C. Sacral Promontory
D. Low Apgar score D. Symphysis pubis

31. Which of the following is a risk factor for macrosomia? 36. The amniotic fluid of a client has a greenish tint. The
nurse interprets this to be the result of which of the
A. Diabetes mellitus
following?
B. Female fetus
A. Meconium
C. Preeclampsia
B. Vernix
D. Oligohydramnios
C. Lanugo

D. Hydramnio
32. Regarding the near-term fetus, which of the following
statements is false?
37. In the late 1950s, consumers and health care
A. They possess four behavioral states (quiet sleep, active
professionals began challenging the routine use of
sleep, quiet awake, active awake), which closely resemble
analgesics and anesthetics during childbirth. Which of the A. Under age 3
following was an outgrowth of this concept?
B. Over age 3
A. Labor, delivery, recovery, postpartum (LDRP)
C. Critically ill and under age 3
B. Clinical nurse specialist
D. Critically ill and over age 3
C. Nurse-midwifery

D. Prepared childbirth
43. When assessing a child’s cultural background, the nurse
in charge should keep in mind that:

38. A client 12 weeks’ pregnant come to the emergency A. Cultural background usually has little bearing on a family’s
department with abdominal cramping and moderate vaginal health practices
bleeding. Speculum examination reveals 2 to 3 cms cervical
dilation. The nurse would document these findings as which B. Physical characteristics mark the child as part of a
of the following? particular culture

A. Imminent abortion C. Heritage dictates a group’s shared values

B.Missed abortion D. Behavioral patterns are passed from one generation to

the next
C. Complete abortion

D.Threatened abortion
44. While examining a 2-year-old child, the nurse in charge
sees that the anterior fontanel is open. The nurse should:

39. Which of the following would be the priority nursing A. Notify the doctor
diagnosis for a client with an ectopic pregnancy?
B. Look for other signs of abuse
A. Knowledge deficit
C. Recognize this as a normal finding
B. Anticipatory grieving
D. Ask about a family history of Tay-Sachs disease
C. Pain

D. Risk for infection

45. The nurse is aware that the most common assessment
finding in a child with ulcerative colitis is:

40. Which of the following should the nurse do when a A. Intense abdominal cramps
primipara who is lactating tells the nurse that she has sore
nipples? B. Profuse diarrhea

A. Encourage her to wear a nursing brassiere C. Anal fissures

B. Administer a narcotic before breast feeding D. Abdominal distention

C. Tell her to breast feed more frequently

D. Use soap and water to clean the nipples 46. When administering an I.M. injection to an infant, the
nurse in charge should use which site?
41. Molly, with suspected rheumatic fever, is admitted to the
pediatric unit. When obtaining the child’s history, the nurse A. Deltoid
considers which information to be most important?
B. Dorsogluteal
A. A fever that started 3 days ago
C. Ventrogluteal
B. Lack of interest in food
D. Vastus lateralis
C. A recent episode of pharyngitis

D. Vomiting for 2 days

47. A child with a poor nutritional status and weight loss is at
risk for a negative nitrogen balance. To help diagnose this
problem, the nurse in charge anticipates that the doctor will
42. Nurse Analiza is administering a medication via the order which laboratory test?
intraosseous route to a child. Intraosseous drug
administration is typically used when a child is: A. Total iron-binding capacity
B. Hemoglobin nursery school 2 days a week. Which principle should guide
the nurse’s response?
C. Total protein
A. The child forgets previously learned skills
D. Serum transferrin
B. The child experiences growth while regressing,
regrouping, and then progressing

48. When developing a plan of care for a male adolescent, C. The parents may refer less mature behaviors
the nurse considers the child’s psychosocial needs. During
adolescence, psychosocial development focuses on: D. The child returns to a level of behavior that increases the
sense of security.
A. Becoming industrious

B. Establishing an identity
53. A female child, age 6, is brought to the health clinic for a
C. Achieving intimacy routine checkup. To assess the child’s vision, the nurse
should ask:
D. Developing initiative
A. “Do you have any problems seeing different colors?”

B. “Do you have trouble seeing at night?”

49. When developing a plan care for a hospitalized child,
nurse Mica knows that children in which age group is most C. “Do you have problems with glare?”
likely to view illness as a punishment for misdeeds?
D. “How are you doing in school?”
A. Infancy

B. Preschool age
54. During a well-baby visit, Liza asks the nurse when she
C. School age should start giving her infant solid foods. The nurse should
instruct her to introduce which solid food first?
D. Adolescence
A. Applesauce

B. Egg whites
50. Nurse Sunshine suspects that a child, age 4, is being
neglected physically. To best assess the child’s nutritional C. Rice cereal
status, the nurse should ask the parents which question?
D. Yogurt
A. “Has your child always been so thin?”

B. “Is your child a picky eater?”

55. To decrease the likelihood of bradyarrhythmias in
C. “What did your child eat for breakfast?” children during endotracheal intubation, succinylcholine
(Anectine) is used with which of the following agents?
D. “Do you think your child eats enough?”
A. Epinephrine (Adrenalin)

B. Isoproterenol (Isuprel)
51. A female child, age 2, is brought to the emergency
department after ingesting an unknown number of aspirin C. Atropine sulfate
tablets about 30 minutes earlier. On entering the
examination room, the child is crying and clinging to the D. Lidocaine hydrochloride (Xylocaine)
mother. Which data should the nurse obtain first?

A. Heart rate, respiratory rate, and blood pressure

56. A 1-year-and 2-month-old child weighing 26 lb (11.8 kg)
B. Recent exposure to communicable diseases is admitted for traction to treat congenital hip dislocation.
When preparing the patient’s room, the nurse anticipates
C. Number of immunizations received using which traction system?

D. Height and weight A. Bryant’s traction

B. Buck’s extension traction

52. A mother asks the nurse how to handle her 5-year-old C. Overhead suspension traction
child, who recently started wetting the pants after being
completely toilet trained. The child just started attending D. 90-90 traction
57. Hannah, age 12, is 7 months pregnant. When teaching 62. Dr. Jones prescribes corticosteroids for a child with
parenting skills to an adolescent, the nurse knows that which nephritic syndrome. What is the primary purpose of
teaching strategy is least effective? administering corticosteroids to this child?

A. Providing a one-on-one demonstration and requesting a A. To increase blood pressure

return demonstration, using a live infant model
B. To reduce inflammation
B. Initiating a teenage parent support group with first – and –
second-time mothers C. To decrease proteinuria

C. Using audiovisual aids that show discussions of feelings D. To prevent infection

and skills

D. Providing age-appropriate reading materials

63. Parents bring their infant to the clinic, seeking treatment
for vomiting and diarrhea that has lasted for 2 days. On
assessment, the nurse in charge detects dry mucous
58. When performing a physical examination on an infant, membranes and lethargy. What other findings suggests a
the nurse in charge notes abnormally low-set ears. This fluid volume deficit?
finding is associated with:
A. A sunken fontanel
A. Otogenous tetanus
B. Decreased pulse rate
B. Tracheoesophageal fistula
C. Increased blood pressure
C. Congenital heart defects
D. Low urine specific gravity
D. Renal anomalies

64. How should the nurse prepare a suspension before

59. Nurse Walter should expect a 3-year-old child to be able administration?
to perform which action?
A. By diluting it with normal saline solution
A. Ride a tricycle
B. By diluting it with 5% dextrose solution
B. Tie the shoelaces
C. By shaking it so that all the drug particles are dispersed
C. Roller-skates uniformly

D. Jump rope D. By crushing remaining particles with a mortar and pestle

60. Nurse Kim is teaching a group of parents about otitis 65. What should be the initial bolus of crystalloid fluid
media. When discussing why children are predisposed to replacement for a pediatric patient in shock?
this disorder, the nurse should mention the significance of
which anatomical feature? A. 20 ml/kg

A. Eustachian tubes B. 10 ml/kg

B. Nasopharynx C. 30 ml/kg

C. Tympanic membrane D. 15 ml/kg

D. External ear canal

61. The nurse is evaluating a female child with acute post 66. Lily , age 5, with an intelligence quotient of 65 is admitted
streptococcal glomerulonephritis for signs of improvement. to the hospital for evaluation. When planning care, the nurse
Which finding typically is the earliest sign of improvement? should keep in mind that this child is:

A. Increased urine output A. Within the lower range of normal intelligence

B. Increased appetite B. Mildly retarded but educable

C. Increased energy level C. Moderately retarded but trainable

D. Decreased diarrhea D. Completely dependent on others for care

67. Mandy, age 12, is brought to the clinic for evaluation for A. From head to toe
a suspected eating disorder. To best assess the effects of
role and relationship patterns on the child’s nutritional intake, B. Distally to proximally
the nurse should ask:
C. From abdomen to toes, the to head
A. “What activities do you engage in during the day?”
D. From least to most intrusive
B. “Do you have any allergies to foods?”

C. “Do you like yourself physically?”

73. Which of the following organisms is responsible for the
D. “What kinds of food do you like to eat?” development of rheumatic fever?

A. Streptococcal pneumonia

68. Sudden infant death syndrome (SIDS) is one of the most B. Haemophilus influenza
common causes of death in infants. At what age is the
diagnosis of SIDS most likely? C. Group A β-hemolytic streptococcus

A. At 1 to 2 years of age D. Staphylococcus aureus

B. At I week to 1 year of age, peaking at 2 to 4 months

C. At 6 months to 1 year of age, peaking at 10 months 74. Which of the following is most likely associated with a
cerebrovascular accident (CVA) resulting from congenital
D. At 6 to 8 weeks of age heart disease?

A. Polycythemia

69. When evaluating a severely depressed adolescent, the B. Cardiomyopathy

nurse knows that one indicator of a high risk for suicide is:
C. Endocarditis
A. Depression
D. Low blood pressure
B. Excessive sleepiness

C. A history of cocaine use

75. How does the nurse appropriately administer Mycostatin
D. A preoccupation with death suspension in an infant?

A. Have the infant drink water, and then administer

myostatin in a syringe
70. A child is diagnosed with Wilms’ tumor. During
assessment, the nurse in charge expects to detect: B. Place Mycostatin on the nipple of the feeding bottle and
have the infant suck it
A. Gross hematuria
C. Mix Mycostatin with formula
B. Dysuria
D. Swab Mycostatin on the affected areas
C. Nausea and vomiting

D. An abdominal mass
76. A newborn is having difficulty maintaining a temperature
71. Which of the following would be inappropriate when above 98 degrees Fahrenheit and has been placed in a
administering chemotherapy to a child? warming isolette. Which action is a nursing priority?

A. Monitoring the child for both general and specific adverse A. Protect the eyes of the neonate from the heat lamp
effects
B. Monitor the neonate’s temperature
B. Observing the child for 10 minutes to note for signs of
anaphylaxis C. Warm all medications and liquids before giving

C. Administering medication through a free-flowing D. Avoid touching the neonate with cold hands
intravenous line

D. Assessing for signs of infusion infiltration and irritation

77. At a senior citizens meeting a nurse talks with a client
who has diabetes mellitus Type 1. Which statement by the
client during the conversation is most predictive of a
72. Which of the following is the best method for performing potential for impaired skin integrity?
a physical examination on a toddler
A. “I give my insulin to myself in my thighs.” D. There is a greater chance for error during preparation

B. “Sometimes when I put my shoes on I don’t know where

my toes are.”
82. Which of the following would cause a false-positive result
C. “Here are my up and down glucose readings that I wrote on a pregnancy test?
on my calendar.”
A. The test was performed less than 10 days after an
D. “If I bathe more than once a week my skin feels too dry.” abortion

B. The test was performed too early or too late in the

pregnancy
78. A 4-year-old hospitalized child begins to have a seizure
while playing with hard plastic toys in the hallway. Of the C. The urine sample was stored too long at room
following nursing actions, which one should the nurse do temperature
first?
D. A spontaneous abortion or a missed abortion is
A. Place the child in the nearest bed impending

B. Administer IV medication to slow down the seizure

C. Place a padded tongue blade in the child’s mouth 83. FHR can be auscultated with a fetoscope as early as
which of the following?
D. Remove the child’s toys from the immediate area
A. 5 weeks gestation

B. 10 weeks gestation
79. The nurse is at the community center speaking with
retired people. To which comment by one of the retirees C. 15 weeks gestation
during a discussion about glaucoma would the nurse give a
supportive comment to reinforce correct information? D. 20 weeks gestation

A. “I usually avoid driving at night since lights sometimes

seem to make things blur.”
84. A client LMP began July 5. Her EDD should be which of
B. “I take half of the usual dose for my sinuses to maintain the following?
my blood pressure.”
A. January 2
C. “I have to sit at the side of the pool with the grandchildren
since I can’t swim with this eye problem.” B. March 28

D. “I take extra fiber and drink lots of water to avoid getting C. April 12
constipated.”
D. October 12

80. The nurse is teaching a parent about side effects of

85. Which of the following fundal heights indicates less than
routine immunizations. Which of the following must be
12 weeks’ gestation when the date of the LMP is unknown?
reported immediately?
A. Uterus in the pelvis
A. Irritability
B. Uterus at the xiphoid
B. Slight edema at site
C. Uterus in the abdomen
C. Local tenderness
D. Uterus at the umbilicus
D. Temperature of 102.5 F

86. Which of the following danger signs should be reported

81. Which of the following would be a disadvantage of
promptly during the antepartum period?
breastfeeding?
A. Constipation
A. Involution occurs more rapidly
B. Breast tenderness
B. The incidence of allergies increases due to maternal
antibodies C. Nasal stuffiness
C. The father may resent the infant’s demands on the D. Leaking amniotic fluid
mother’s body
87. Which of the following prenatal laboratory test values 92. Which of the following actions demonstrates the nurse’s
would the nurse consider as significant? understanding of the newborn’s thermoregulatory ability?

A. Hematocrit 33.5% A. Placing the newborn under a radiant warmer.

B. Rubella titer less than 1:8 B. Suctioning with a bulb syringe

C. White blood cells 8,000/mm3 C. Obtaining an Apgar score

D. One hour glucose challenge test 110 g/dL D. Inspecting the newborn’s umbilical cord

88. Which of the following characteristics of contractions 93. Immediately before expulsion, which of the following
would the nurse expect to find in a client experiencing true cardinal movements occur?
labor?
A. Descent
A. Occurring at irregular intervals
B. Flexion
B. Starting mainly in the abdomen
C. Extension
C. Gradually increasing intervals
D. External rotation
D. Increasing intensity with walking

95. Before birth, which of the following structures connects

89. During which of the following stages of labor would the the right and left auricles of the heart?
nurse assess “crowning”?
A. Umbilical vein
A. First stage
B. Foramen ovale
B. Second stage
C. Ductus arteriosus
C. Third stage
D. Ductus venosus
D. Fourth stage

95. Which of the following when present in the urine may

90. Barbiturates are usually not given for pain relief during cause a reddish stain on the diaper of a newborn?
active labor for which of the following reasons?
A. Mucus
A. The neonatal effects include hypotonia, hypothermia,
generalized drowsiness, and reluctance to feed for the first B. Uric acid crystals
few days.
C. Bilirubin
B. These drugs readily cross the placental barrier, causing
depressive effects in the newborn 2 to 3 hours after D. Excess iron
intramuscular injection.
96. When assessing the newborn’s heart rate, which of the
C. They rapidly transfer across the placenta, and lack of an following ranges would be considered normal if the newborn
antagonist make them generally inappropriate during labor. were sleeping?

D. Adverse reactions may include maternal hypotension, A. 80 beats per minute

allergic or toxic reaction or partial or total respiratory failure
B. 100 beats per minute

C. 120 beats per minute

91. Which of the following nursing interventions would the
D. 140 beats per minute
nurse perform during the third stage of labor?

A. Obtain a urine specimen and other laboratory tests.

97. Which of the following is true regarding the fontanels of
B. Assess uterine contractions every 30 minutes.
the newborn?
C. Coach for effective client pushing
A. The anterior is triangular shaped; the posterior is diamond
D. Promote parent-newborn interaction. shaped.
B. The posterior closes at 18 months; the anterior closes at 8 B. The newborn abducts and flexes all extremities and may
to 12 weeks. begin to cry when exposed to sudden movement or loud
noise.
C. The anterior is large in size when compared to the
posterior fontanel. C. The newborn turns the head in the direction of stimulus,
opens the mouth, and begins to suck when cheek, lip, or
D. The anterior is bulging; the posterior appears sunken. corner of mouth is touched.

D. The newborn will attempt to crawl forward with both arms

and legs when he is placed on his abdomen on a flat surface
98. Which of the following groups of newborn reflexes below
are present at birth and remain unchanged through
adulthood?
100. Which of the following statements best describes
A. Blink, cough, rooting, and gag hyperemesis gravidarum?

B. Blink, cough, sneeze, gag A. Severe anemia leading to an electrolyte, metabolic, and
nutritional imbalances in the absence of other medical
C. Rooting, sneeze, swallowing, and cough problems.
D. Stepping, blink, cough, and sneeze B. Severe nausea and vomiting leading to an electrolyte,
metabolic, and nutritional imbalances in the absence of other
medical problems.
99. Which of the following describes the Babinski reflex?
C. Loss of appetite and continuous vomiting that commonly
A. The newborn’s toes will hyperextend and fan apart from results in dehydration and ultimately decreasing maternal
dorsiflexion of the big toe when one side of foot is stroked nutrients
upward from the ball of the heel and across the ball of the
D. Severe nausea and diarrhea that can cause
foot.
gastrointestinal irritation and possibly internal bleeding

SECOND SET OF QUESTIONAIRE

I. Multiple Choice. Write your answers beside the number D. Fostering the parent-child relationship
ONLY.
E. Giving vaccination for preventing tetanus

101. 9-month-old child has been treated after a choking

incident. Which advice does the nurse give to the parents to 105. The parent of a newborn child asks the nurse the
prevent further incidents? Select all that apply. importance of breastfeeding. What should the nurse tell the
parent? Select all that apply.
A. Never leave your child unattended.
A. Breast milk is not rich in micronutrients.
B. Your child is too young to be allowed to eat solid food.
B. Breast milk is not recommended for infants with fever.
C. Make sure all cabinets, drawers, and containers are
childproof. C. Enzymes in breast milk are helpful in the digestion of milk.

D. Marbles and LEGOs are not appropriate toys for children D. Immunoglobulins in milk can prevent infections and
at that age. diseases.

E. Allowing your child to crawl on the floor increases the risk E. Breastfeeding can decrease infant mortality and
for injury. morbidity.

102. The nurse is assessing a school-age child. The child 106. The nurse has to follow a method of problem
stays with a parent who is recently divorced and has a identification and problem solving. Arrange the steps of the
meager income. The child does not like to mingle with other nursing process model in an appropriate order.
students at school. The child's performance is poor in
studies and is cruel toward pets at home. Which factors in A. Planning
the child could most likely lead to pediatric social illness?
B. Evaluation
Select all that apply.
C. Diagnosis
A. Poverty
D. Assessment
B. Pet cruelty
E. Implementation
C. Single parent

D. Going to school
107. The nurse finds that a child spends several hours each
E. Behavior with others
day playing video games and lives in a home environment
with limited access to safe playgrounds and parks. What
health risks does the nurse expect based on these findings?
103. The nurse is caring for a patient who is on long-term Select all that apply.
catheterization. According to the National Quality Forum,
what should the nurse assess in this patient? A. Tooth decay

A. Oxygen saturation using arterial or venous blood B. Hypertension

B. Monitoring of respiratory rate while in a sitting position C. Diabetes

C. Signs and symptoms of a urinary tract infection D. Growth delays

D. Abnormal changes in the electrocardiogram (ECG) E. Hypercholesterolemia

104. The pediatric nurse is providing first aid to a child. The 108. The nurse is instructing the parents of a 6-month-old
child sustained minor injuries while playing on the ground, child about the dietary requirements and factors that may
and has severe pain in the knee joint. Which of the nursing influence the eating habits of the child. Which statement
interventions in the care of the child come under atraumatic made by the nurse is appropriate? Select all that apply.
care? Select all that apply.
A. Culture will have some influence on children's eating
A. Controlling pain habits.

B. Allowing the child's privacy B. Cholesterol is required for the synthesis of neurons in
child's brain.
C. Respecting cultural differences
C. During adolescence, children tend to make food choices 112. The nurse is teaching care of the newborn to a
for sociability. childbirth preparation class and describes the need for
administering antibiotic ointment into the eyes of the
D. First 3 years of life are crucial in establishing eating habits newborn. An expectant father asks, "What type of disease
of children. causes infections in babies that can be prevented by using
this ointment?" Which response by the nurse is accurate?
E. Cholesterol content is high in nuts and vegetable oils so
use them sparingly. A. NHerpes

B. Trichomonas

109. The role of the pediatric nurse is influenced by trends in C. Gonorrhea

health care. The greatest trend in health care is:
D. Syphilis
A. primary focus on treatment of disease or disability.

B. national health care planning on a distributive or episodic

basis. 113. A new mother is having trouble breastfeeding her
newborn. The child is making frantic rooting motions and will
C. accountability to professional codes and international not grasp the nipple. Which intervention should the nurse
standards. implement?

D. shift of focus to prevention of illness and maintenance of A. Encourage frequent use of a pacifier so that the infant
health. becomes accustomed to sucking.

B. Hold the infant's head firmly against the breast until he

latches onto the nipple.
110. The nurse is teaching a pregnant woman to eat a
nutritious diet and to attend regular antenatal health check- C. Encourage the mother to stop feeding for a few minutes
ups for the assessment of fetal well-being. The primary and comfort the infant.
purpose of this nursing intervention is to reduce the neonatal
D. Provide formula for the infant until he becomes calm, and
mortality rate due to:
then offer the breast again.
A. birth weight less than 2.5g.

B. gestational diabetes in mother.

114. The nurse is counseling a couple who has sought
C. birth weight of more than 3.5 g. information about conceiving. The couple asks the nurse to
explain when ovulation usually occurs. Which statement by
D. febrile convulsions in neonate the nurse is correct?

A. Two weeks before menstruation

111. A client who delivered by cesarean section 24 hours B. Immediately after menstruation
ago is using a patient-controlled analgesia (PCA) pump for
pain control. Her oral intake has been ice chips only since C. Immediately before menstruation
surgery. She is now complaining of nausea and bloating,
D. Three weeks before menstruation
and states that because she had nothing to eat, she is too
weak to breastfeed her infant. Which nursing diagnosis has
the highest priority?
115. The nurse instructs a laboring client to use accelerated
A. Altered nutrition, less than body requirements for lactation blow breathing. The client begins to complain of tingling
fingers and dizziness. Which action should the nurse take?
B. Alteration in comfort related to nausea and abdominal
distention A. Administer oxygen by face mask.
C. Impaired bowel motility related to pain medication and B. Notify the health care provider of the client's symptoms.
immobility
C. Have the client breathe into her cupped hands.
D.Fatigue related to cesarean delivery and physical care
demands of infant D. Check the client's blood pressure and fetal heart rate.

116. When assessing a client at 12 weeks of gestation, the

nurse recommends that she and her husband consider
attending childbirth preparation classes. When is the best
time for the couple to attend these classes?
A. At 16 weeks of gestation D. Notify the health care provider.

B. At 20 weeks of gestation

C. At 24 weeks of gestation 121.The nurse needs to take the blood pressure of a

preschool boy for the first time. Which action is best in
D. At 30 weeks of gestation gaining his cooperation?

117. One hour following a normal vaginal delivery, a A. Take his blood pressure when a parent is there to comfort
newborn infant boy's axillary temperature is 96° F, his lower him.
lip is shaking and, when the nurse assesses for a Moro
reflex, the boy's hands shake. Which intervention should the B. Tell him that this procedure will help him get well more
nurse implement first? quickly.

A. Stimulate the infant to cry. C. Explain to him how the blood flows through the arm and
why the blood pressure is important.
B. Wrap the infant in warm blankets.
D. Permit him to handle equipment and see the dial move
C. Feed the infant formula. before putting the cuff in place.

D. Obtain a serum glucose level.

118. Which statement made by the client indicates that the 122.The nurse finds that a patient has developed
mother understands the limitations of breastfeeding her tachycardia and tachypnea after administration of a muscle
newborn? relaxant. What is an appropriate nursing action?

A. "Breastfeeding my infant consistently every 3 to 4 hours A. Administer dantrolene sodium intravenously.

stops ovulation and my period."
B. Use hot compresses on the neck and axillae.
B. "Breastfeeding my baby immediately after drinking alcohol
is safer than waiting for the alcohol to clear my breast milk. " C. Assess the patient's history of surgical procedures.

C. "I can start smoking cigarettes while breastfeeding D. Administer an inhaled anesthetic.
because it will not affect my breast milk. "
123.What does the nurse keep in mind while administering
D. "When I take a warm shower after I breastfeed, it relieves an enema to a child?
the pain from being engorged between breastfeedings. "
A. The nurse should not give details about the procedure.
119. A client at 30 weeks of gestation is on bed rest at home
because of increased blood pressure. The home health B. The buttocks of the child should be held together briefly.
nurse has taught her how to take her own blood pressure
and gave her parameters to judge a significant increase in C. Pillows should not be used during the procedure.
blood pressure. When the client calls the clinic complaining
D. Administration of enemas should be noninvasive in
of indigestion, which instruction should the nurse provide?
children.
A. Lie on your left side and call 911 for emergency
assistance.
124.Several types of long-term central venous access
B. Take an antacid and call back if the pain has not
devices are used. A benefit of using an implanted port (e.g.,
subsided.
Port-a-Cath) is that it:
C. Take your blood pressure now and if it is seriously
A. Is easy to use for self-administered infusions.
elevated, go to the hospital.
B. Does not need to pierce the skin for access.
D. See your health care provider to obtain a prescription for
a histamine blocking agent. C. Does not need to limit regular physical activity, including
swimming.
120. The nurse observes that an antepartum client who is on
bed rest for preterm labor is eating ice rather than the food D. Cannot dislodge from the port, even if child plays with port
on her breakfast tray. The client states that she has a site.
craving for ice and then feels too full to eat anything else.
Which is the best response by the nurse?

A. Remove all ice from the client's room. 125. Nurses play an important role in current issues and
trends in health care. What is a current trend in pediatric
B. Ask the client what foods she might consider eating. nursing and health care today?
C. Remind the client that what she eats affects her baby. A. The patient is the unit of care for the health care provider.
B. Discharge planning begins when the physician writes the 129.The pediatric nurse is working on a project to contribute
order. to research and evidence-based practice. What should the
nurse do when caring for patients of different age groups?
C. Health promotion resources enable children to achieve Arrange the following steps in the correct order.
their full potential.
A. Develop a care plan.
D. The focus of pediatric health care is trending toward acute
hospital care. B. Evaluate the effectiveness of intervention

C. Collect information.

126. The signs and symptoms in a nursing diagnosis D. Identify specific questions.
describe:

A. Projected changes in an individual's health status, clinical

conditions, or behavior. 130. Which actions of the nurse indicate that the nurse is
providing atraumatic care to the patient who is admitted in
B. An individual's response to health pattern deficits in the the intensive care unit and his or her family? Select all that
child, family, or community. apply.

C. A cluster of cues and/or defining characteristics that are A. The nurse patiently listens to the parent's concerns.
derived from patient assessment and indicate actual health
problems. B. The nurse spends off-duty time playing with the child.

D. Physiologic, situational, and maturational factors that C. The nurse allows a parent to stay with the child at all
cause the problem or influence its development. times.

D. The nurse gives the appropriate pain medications to the

child.
127.While caring for a child, the nurse provides small toys
and works overtime to take care of the child, and even calls E The nurse explains the treatment given to the child to the
the hospital during off-duty time to find out whether the child parents
is improving. The nurse regularly meets the mother outside
of the hospital. The nurse asks the mother if she is involved
in care of the child. Which actions of the nurse indicate a
131.The nurse is evaluating the quality of evidence of
nontherapeutic nurse-patient relationship? Select all that
research found in the field of infectious diseases in infants.
apply.
The nurse found unusually strong evidence from unbiased
A. Giving a toy to the child observational studies. What grade should be given to this
research according to the GRADE criteria?
B. Working overtime to look after the child
A. Low
C. Calling the hospital frequently to inquire about the child
B. High
D. Asking whether the mother is involved in care of the child
C. Very low
E. Meeting the mother outside of the hospital to discuss the
child D. Moderate

128. The pediatric nurse works efficiently in providing 132.What important information should the nurse include
nursing care to an acutely ill child. After discharge, parents when teaching the parents of an adolescent about nutrition?
of the child ask the nurse to visit their home for dinner. What
A. Adolescents are usually mature enough to make healthy
should the nurse do?
food choices.
A. Accept it; otherwise it may adversely affect the good
B. Resources are available to assist lower income families to
relationship.
obtain enough protein.
B. Tell them to schedule it later as it is a busy day in
C. Behavior problems in this age group are not related to
hospital.
nutritional deficiencies.
C. Reject it courteously and thank them for the invitation.
D. Parental influence has the greatest impact on food
D. Ask them to invite other staff who were involved in the choices at this age.
care as well.

133. A patient is put on a ventilator in the intensive care unit

of a tertiary hospital for long-term care. While caring for the
patient, the nurse continuously assesses the health status of D. Refer the matter to the dietician.
the patient. How does this intervention affect the patient's
outcome? It prevents:

A. Pneumonia. 138.The nurse is speaking with the parents of a child with a

very high fever. Which statement by the child's parent
B. Lung cancer. indicates a need for additional teaching?

C. Cystic fibrosis. A. "The temperature is quite high. It's life-threatening."

D. Pulmonary edema. B. "I guess chills are common during high fever."

134. The nurse is leading an educational program for C. "Antipyretics should bring down the temperature."
parents of 5- to 9-year-old children. Which topic should the
nurse include in the teaching plan to prevent childhood D. "Fever has its own advantages for the body."
mortality in children of this age?

A. Suicide
139.A 9-year-old patient is scheduled for a surgical
B. Being overweight procedure next week. What teachings will the nurse include
to ensure the patient's assent? Select all that apply:
C. Heart diseases
A. Inform the patient about the nature of the condition.
D. Unintentional injuries
B. Tell the patient what can be expected.

C. Inform the patient how consent is obtained.

135. Parents inform the nurse that they had noticed some
needle injuries on their child's left elbow and some syringes D. Assess patient understanding.
and needles in the child's school bag. What should the nurse
suggest to the child's parent? Select all that apply. E. Solicit an expression of the patient's willingness.

A. Encourage the child to participate in scouts.

B. Discourage the child from participating in sports due to 140.The nurse is administering an antipyretic medication to a
injury. child with a high fever. What action does the nurse take in
the first hour after giving the medication?
C. Encourage the child to participate in church activities.
A. Check the temperature again.
D. Provide first aid to the child and apply bandage to elbow.
B. Administer another dose.
E. Educate the parent and children about the ill effects of
drugs. C. Check the child's weight.

D. Check for aspirin toxicity.

136.The nurse is educating new parents about the 141. A nurse is teaching women the importance of good
prevention of sudden infant death syndrome (SIDS). What nutrition and taking prenatal vitamins if they are planning
position does the nurse tell the parents is the best sleeping pregnancy. Which measure is the nurse performing?
position for their infant?
A. Health promotion
A. Supine
B. Health maintenance
B. Prone
C. Health restoration
C. On the side
D. Health rehabilitation
D. On a chair

142. The family is the basic unit of society. Which statement

137.The nurse is caring for a child after surgery. The child correctly illustrates the importance of this concept related to
refuses to eat any food for lunch. What is an appropriate how society functions?
intervention by the nurse?
A. Healthy, well-functioning families provide members of all
A. Insist that the child eat some more food. ages with fulfilling, supporting relationships.

B. Give the child a favorite food.

C. Call the child's parents.

B. The family serves as a place that encourages members to
autonomously function in pursuit of personal pleasures.
146. A 15-year-old client has just given birth and states that
she does not want her infant to receive any newborn
vaccines. What is the appropriate action for the nurse to
take?
C. Society functions best when families determine how they
will interface with others without having to deal with the A. Administer the newborn vaccines.
overall consequences.

D. Work is an important part of family function but is not

B. Withhold the vaccines.
necessary for success if one member can fulfill multiple
roles. C. Call the primary care provider.

143. A nurse is reviewing statistics about maternal and child

health. Which rate would the nurse identify as reflecting the D. Ask the grandparents for permission.
proportion of women who could have babies that are having
them?

A. Fertility rate 147. It is the 6 weeks after child birth, sometimes termed as
the 4th trimester of pregnancy.
B. Birth rate
A. Puerperium
C. Morbidity rate
B. Perinatal Period
D. Implantation rate
C. Neonatal Period

D. None of the above

144. A nurse educator is conducting a class on abuse and
violence for a group of new graduate nurses during
orientation. Which statement by the educator best reflects
current practice regarding these problems in women's 148. What is nullipara?
health?
A. Someone who has never delivered
A. "Asking every client about abuse and family violence is
B. Someone who has never pregnant
the best way to elicit accurate information."
C. Someone who has never eat
B. "The nurse should screen for these problems at every
client encounter." D. Someone who has never urinate
C. "The nurse is not legally responsible for reporting
suspected abuse or violence."
149. When assessing the adequacy of sperm for conception
D. "Since families are more stable than in the past, nurses to occur, which of the following is the most useful criterion?
are not as concerned about these problems as they used to
be." A. Sperm count

B. Sperm motility
145. When integrating the principles of family-centered care, C. Sperm maturity
the nurse would NOT include:
D. Semen volume
A. Parents want to make decisions about their child's
treatment.

B. Families can make informed choices. 150. A couple who wants to conceive but has been
unsuccessful during the last 2 years has undergone many
diagnostic procedures. When discussing the situation with
the nurse, one partner states, “We know several friends in
our age group, and all of them have their own child already,
C. People have taken less responsibility for their own health.
Why can’t we have one?”. Which of the following would be
the most appropriate nursing diagnosis for this couple?

D. Families require more information to make appropriate A. Fear related to the unknown
decisions.
B. Pain related to numerous procedures. D. 25 to 40 lb

C. Ineffective family coping related to infertility.

D. Self-esteem disturbance related to infertility. 156. When talking with a pregnant client who is experiencing
aching swollen, leg veins, the nurse would explain that this is
most probably the result of which of the following?

151. Which of the following urinary symptoms does the A. Thrombophlebitis

pregnant woman most frequently experience during the first
trimester? B. Pregnancy-induced hypertension

A. Dysuria C. Pressure on blood vessels from the enlarging uterus

B. Frequency D. The force of gravity pulling down on the uterus

C. Incontinence

D. Burning 157. Cervical softening and uterine souffle are classified as

which of the following?

A. Diagnostic signs
152. Heartburn and flatulence, common in the second
trimester, are most likely the result of which of the following? B. Presumptive signs

A. Increased plasma HCG levels C. Probable signs

B. Decreased intestinal motility D. Positive signs

C. Decreased gastric acidity

D. Elevated estrogen levels 158. Which of the following would the nurse identify as a
presumptive sign of pregnancy?

A. Hegar sign
153. On which of the following areas would the nurse expect
to observe chloasma? B. Nausea and vomiting

A. Breast, areola, and nipples C. Skin pigmentation changes

B. Chest, neck, arms, and legs

C. Abdomen, breast, and thighs

D. Positive serum pregnancy test
D. Cheeks, forehead, and nose

159. Which of the following common emotional reactions to

154. A pregnant client states that she “waddles” when she pregnancy would the nurse expect to occur during the first
walks. The nurse’s explanation is based on which of the trimester?
following as the cause?
A. Introversion, egocentrism, narcissism
A. The large size of the newborn
B. Awkwardness, clumsiness, and unattractiveness
B. Pressure on the pelvic muscles

C. Relaxation of the pelvic joints

D. Excessive weight gain C. Anxiety, passivity, extroversion

155. Which of the following represents the average amount

of weight gained during pregnancy? D. Ambivalence, fear, fantasies

A. 12 to 22 lb

B. 15 to 25 lb 160. During which of the following would the focus of classes

be mainly on physiologic changes, fetal development,
C. 24 to 30 lb sexuality, during pregnancy, and nutrition?
A. Prepregnant period C. Use commercial baby wipes with each diaper change

B. First trimester D. Discontinue a new food that was added to the infant’s diet
just prior to the rash
C. Second trimester

D. Third trimester
165. A 16-year-old client is admitted to a psychiatric unit with
a diagnosis of attempted suicide. The nurse is aware that the
most frequent cause of suicide in adolescents is
161. A 57-year-old male client has hemoglobin of 10 mg/dl
and a hematocrit of 32%. What would be the most A. Progressive failure to adapt
appropriate follow-up by the home care nurse?
B. Feelings of anger or hostility
A. Ask the client if he has noticed any bleeding or dark stools
C. Reunion wish or fantasy
B. Tell the client to call 911 and go to the emergency
department immediately D. Feelings of alienation or isolation

C. Schedule a repeat Hemoglobin and Hematocrit in 1

month
166. A mother brings her 26-month-old to the well-child
D. Tell the client to schedule an appointment with a clinic. She expresses frustration and anger due to her child’s
hematologist constantly saying “no” and his refusal to follow her
directions. The nurse explains this is normal for his age, as
negativism is attempting to meet which developmental
need?
162. Which response by the nurse would best assist the
chemically impaired client to deal with issues of guilt? A. Trust

A. “Addiction usually causes people to feel guilty. Don’t B. Initiative

worry, it is a typical response due to your drinking behavior.”
C. Independence
B. “What have you done that you feel most guilty about and
what steps can you begin to take to help you lessen this D. Self-esteem
guilt?”

C. “Don’t focus on your guilty feelings. These feelings will

only lead you to drinking and taking drugs.” 167. Following mitral valve replacement surgery, a client
develops PVC’s. The health care provider orders a bolus of
D. “You’ve caused a great deal of pain to your family and Lidocaine followed by a continuous Lidocaine infusion at a
close friends, so it will take time to undo all the things you’ve rate of 2 mgm/minute. The IV solution contains 2 grams of
done.” Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60
microdrops/cc. What rate would deliver 4 mgm of
Lidocaine/minute?

163. An adolescent client comes to the clinic 3 weeks after A. 60 microdrops/minute

the birth of her first baby. She tells the nurse she is
concerned because she has not returned to her pre- B. 20 microdrops/minute
pregnant weight. Which action should the nurse perform
first? C. 30 microdrops/minute

A. Review the client’s weight pattern over the year D. 40 microdrops/minute

B. Ask the mother to record her diet for the last 24 hours

C. Encourage her to talk about her view of herself 168. A couple asks the nurse about risks of several birth
control methods. What is the most appropriate response by
D. Give her several pamphlets on postpartum nutrition the nurse?

A. Norplant is safe and may be removed easily

164. Which of the following measures would be appropriate B. Oral contraceptives should not be used by smokers
for the nurse to teach the parent of a nine-month-old infant
about diaper dermatitis? C. Depo-Provera is convenient with few side effects

A. Use only cloth diapers that are rinsed with bleach D. The IUD gives protection from pregnancy and infection

B. Do not use occlusive ointments on the rash

169. The nurse is caring for a client in the late stages of 173. The parents of a newborn male with hypospadias want
Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would their child circumcised. The best response by the nurse is to
the nurse expect? inform them that

A. Confusion A. Circumcision is delayed so the foreskin can be used for

the surgical repair
B. Loss of half of visual field
B. This procedure is contraindicated because of the
C. Shallow respirations permanent defect

D. Tonic-clonic seizures C. There is no medical indication for performing a

circumcision on any child

D. The procedure should be performed as soon as the infant

170. A client experiences postpartum hemorrhage eight is stable
hours after the birth of twins. Following administration of IV
fluids and 500 ml of whole blood, her hemoglobin and
hematocrit are within normal limits. She asks the nurse
whether she should continue to breastfeed the infants. 174. The nurse is teaching parents about the treatment plan
Which of the following is based on sound rationale? for a 2-week-old infant with Tetralogy of Fallot. While
awaiting future surgery, the nurse instructs the parents to
A. “Nursing will help contract the uterus and reduce your risk immediately report
of bleeding.”
A. Loss of consciousness
B. “Breastfeeding twins will take too much energy after the
hemorrhage.” B. Feeding problems

C. “The blood transfusion may increase the risks to you and C. Poor weight gain
the babies.”
D. Fatigue with crying
D. “Lactation should be delayed until the “real milk” is
secreted.”

175. An infant weighed 7 pounds 8 ounces at birth. If growth

occurs at a normal rate, what would be the expected weight
171. A client complained of nausea, a metallic taste in her at 6 months of age?
mouth, and fine hand tremors 2 hours after her first dose of
lithium carbonate (Lithane). What is the nurse’s best A. Double the birth weight
explanation of these findings?
B. Triple the birth weight

C. Gain 6 ounces each week

A. These side effects are common and should subside in a
few days D. Add 2 pounds each month

B. The client is probably having an allergic reaction and

should discontinue the drug
176. The nurse is caring for a 13-year-old following spinal
C. Taking the lithium on an empty stomach should decrease fusion for scoliosis. Which of the following interventions is
these symptoms appropriate in the immediate post-operative period?

D. Decreasing dietary intake of sodium and fluids should A. Raise the head of the bed at least 30 degrees
minimize the side effects
B. Encourage ambulation within 24 hours

C. Maintain in a flat position, logrolling as needed

172. The nurse is caring for a post-surgical client at risk for
D. Encourage leg contraction and relaxation after 48 hours
developing deep vein thrombosis. Which intervention is an
effective preventive measure?

A. Place pillows under the knees 177. A client asks the nurse about including her 2 and 12-
year-old sons in the care of their newborn sister. Which of
B. Use elastic stockings continuously
the following is an appropriate initial statement by the nurse?
C. Encourage range of motion and ambulation
A. “Focus on your son’s’ needs during the first days at
D. Massage the legs twice daily home.”

B. “Tell each child what he can do to help with the baby.”

C. “Suggest that your husband spend more time with the the clinic when “his eyes rolled upward.” The nurse
boys.” recognizes this as what type of side effect?

D. “Ask the children what they would like to do for the A. Oculogyric crisis
newborn.”
B. Tardive dyskinesia

C. Nystagmus
178. A nurse is caring for a 2-year-old child after corrective
surgery for Tetralogy of Fallot. The mother reports that the D. Dysphagia
child has suddenly begun seizing. The nurse recognizes this
problem is probably due to

A. A cerebral vascular accident 180. A home health nurse is at the home of a client with
diabetes and arthritis. The client has difficulty drawing up
B. Postoperative meningitis insulin. It would be most appropriate for the nurse to refer
the client to
C. Medication reaction
A. A social worker from the local hospital
D. Metabolic alkalosis
B. An occupational therapist from the community center

C. A physical therapist from the rehabilitation agency

179. A client with schizophrenia is receiving Haloperidol
(Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls D. Another client with diabetes mellitus and takes insulin

II. Identification. Write your answer beside the number ONLY

181. It is the dizziness and the drop of the blood pressure of the mother.

182. It occurs during pregnancy due to rapid expansion of blood volume.

183. An irregular darkening of the cheeks, forehead, and nose of pregnant women.

184. This is a line of darker pigmentation extending from the umbilicus to the pubis.

185. A sign of pregnancy characterized by an ease in flexing the body of the uterus against the cervix.

186. It is the softening of the lower uterine segment.

187. It is the absence of menstruation.

188. This is the mild uterine contractions that occur throughout pregnancy and become stronger in the last trimester.

189. It is the rebounding of the fetus against the examiner’s finger on palpation.

190. The time between conception and onset of labor.

191. The time between from the onset of true labor until the birth of the infant and expulsion of placenta.

192. The time from the delivery of the placenta and membranes to the return of a woman’s reproductive to its non-pregnant state.
Approx. 6 weeks.

193. A woman who has not completed a pregnancy to at least 20 weeks of gestation.

194. The pregnant woman.

195. The birth after 20 weeks gestation.

196. A woman who has given birth for one pregnancy past 20 weeks.

197. A woman who is pregnant for the first time.

198. Method determining the estimated date of birth (EDB).

199. The excessive salivation.

200. The key hormone of pregnancy.

A. Intrapartum K. Supine Hypotensive

Syndrome
B. Postpartum L. Pseudoanemia
C. Nullipara M. Chloasma
D. Gravida N. Linea Negra
E. Para O. McDonald’s Sign
F. Primipara P. Hegar’s Sign
G. Primigravida Q. Amenorrhea
H. Nagele’s Rule R. Braxton Hicks
I. Ptyalism S. Ballottement
J. hCG T. Antepartum

“DON’T WORRY ABOUT FAILURES, WORRY ABOUT THE

CHANCE YOU MISS WHEN YOU DON’T EVEN TRY.”